Heritage Place Of Decatur

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 residents (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for infection control. The LPC, who was a vendor at the facility, failed to use appropriate PPE according to the facility's IPCP when visiting Residents #1, #2, and #3, who were on isolation precautions with confirmed COVID. This failure could place residents at risk for spread of infection through cross-contamination.Findings included: Resident #1Record review of Resident #1's Quarterly MDS Assessment, dated 12/04/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 14, which indicated her cognition was intact. The MDS Assessment under Section I-Active Diagnoses, reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen and failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated for food service safety in the facility's only kitchen. 1. The facility failed to ensure the deep fryer was cleaned in accordance with professional standards. 2. The facility failed to ensure food items was properly labeled, dated, and thawed in accordance with professional standards. 3. The facility failed to ensure food items stored in the freezer were properly discarded. These failures could place residents at risk from food contamination and food-borne illness. Findings included:Observation on 09/28/25 at 9:08 AM, revealed the deep fryers was layered in grease with food spills and food particles. Observation on 09/28/25 at 9:11 AM, of the refrigerators revealed the following: - a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement its advance directives policy regarding obtaining and placing advanced directives in the clinical record for 1 of 4 residents (Resident #9), reviewed for do not resuscitate status. The facility failed to upload Resident #9's OOH DNR to her clinical record to ensure all staff were aware of her elected resuscitation status. This failure could place residents at risk of not having their end-of-life wishes honored.Findings included: Record review of Resident #9's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnoses included respiratory failure, and she had severe cognitive impairment with a BIMS score (mental assessment) of 5. Record review of Resident #9's care plan initiated on [DATE] and revised on [DATE] reflected the resident was a full code status. The care plan interventions included initiating BLS CPR if the resident was without a heartbeat or not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to provide comfortable and safe temperature levels between 71 to 81 degrees Fahrenheit for 3 of 8 residents (Residents #11, #15, and #38) reviewed for environment.The facility failed to maintain comfortable temperature levels in Residents #11, #15, and #38's rooms.The failure placed residents at risk of a decreased quality of life. Findings included: Observations on 09/28/25 from 10:00 AM-10:30 AM revealed Resident #38 was sitting in his wheelchair in his room with a blanket wrapped around him. Observation on 9/28/25 at 10:10 AM, Resident #15 was sitting in her recliner in her room with a thick jacket on with a heavy blanket covering her.Observation on 9/28/25 at 10:30 AM, Resident #11 in bed with multiple blankets covering her. Observation om 9/28/25 at 10:20 AM of the thermostat in Hall A revealed it was set to 72 degrees F and Cooling. Observation of temperatures, using an ambient thermometer 0n 9/28/25 room temperatures were as follows:At 10:35 AM Resident #38's room temperature was 70 degrees F.At 10:40 AM Resident #15's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program under Medicaid in subpart C of this part to the maximum extent practicable for 2 of 5 residents (Residents #6 and #29) reviewed for PASRR Level 1 screenings.The facility did not correctly identify Resident #6 and #29 as having a mental illness and did not complete a new PASRR Level 1 Screening.These failures could place residents at risk of not being evaluated for PASRR services.Findings included:Record review of Resident #6's Quarterly MDS Assessment, dated 09/01/25, reflected the resident was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Her diagnoses included: schizophrenia (disruptions in thought processes, perceptions emotional responsiveness, and social interactions), bipolar disorder (is a mental illness that causes clear shifts in a person's mood, energy activity levels, and concentrations), anxiety disorder (a condition that occurs when there is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #11) reviewed for comprehensive care plans. The facility failed to ensure Resident #11's psychosocial needs was identified in her care plan. This failure could place residents at risk of not receiving the care they need. Findings included:1.Record review of Resident #11's admission MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety disorder, depression, psychotic disorder, and schizophrenia. The resident's cognition was intact with a BIMS score of 15. Record review of Resident #11's care plan, dated 08/16/25, reflected it addressed the resident's use of anti-psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #9) observed for wound care. RN D failed to sanitize his hands between gloves changes when providing wound care for Resident #9.The failure placed residents at risk for infection.Findings included: Record review of Resident #9's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnosis included respiratory failure. Resident #9 had a BIMS of 5 which indicated the resident had severe cognitive impairment. The MDS further reflected Resident #9 was at risk of developing pressure ulcers/injuries.Record review of Resident #9's care plan revised on 09/22/25 reflected that she had a pressure ulcer to her left heel.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly group meeting for 12 of 12 confidential residents reviewed for resident council. The facility failed to provide a private space for resident group meetings. This failure could place residents, who attended resident group meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting with 12 residents, revealed the meeting was held in the front lobby of the facility near the front door and the Administrator's office door. During this meeting, there were two signs posted. However, multiple staff walked through the space as well as people from the community. One resident stated she did not feel comfortable talking about issues due to staff and administration interrupting the meeting as well as when they have their monthly meetings. Interview on 08/08/24 at 03:54 PM, the Activity Director revealed she became the AD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that menus were followed for 1 of 5 meals (breakfast [08/07/24]) reviewed for meal accuracy. The facility failed to follow the menu for breakfast on 08/07/24. This failure could place residents at risk for poor intake and weight loss. Findings included: Record review for breakfast menu for 08/07/24 reflected the following: Choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine/jelly, milk, coffee. Interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting with 12 residents, revealed residents were told they could not have eggs for breakfast on 08/07/24 because the kitchen was out of eggs. Observation of the kitchen on 08/07/24 at 11:29 AM revealed the kitchen had no eggs to serve for breakfast on 08/07/24. However, further observation revealed the foodservice company did deliver the eggs on 08/07/24 at 11:45 AM. Interview on 08/07/24 at 11:35 AM with the Dietary Manager revealed she had been employed for three months at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 washing machine (Washer A) of 2 reviewed for essential equipment. The facility failed to maintain a laundry washing machine (Washer A) in operating condition. This failure could place residents at risk of not having clean linen for their beds. Findings included: Interview on 08/08/24 at 9:40 AM, Resident #39 stated the facility seemed to have a problem keeping up with linen. He stated a week prior he had to sleep on six bath towels after he had soiled his linen and staff said there were no clean sheets available. Resident #39 stated as President of the Resident Counsel he talked with all the residents, several of whom reported delays in getting their clothing back from laundry and a shortage of linen, especially on the weekends. Interview on 08/08/24 at 10:00 AM. the Laundry Aide stated one washing machine (Washer A) was out of service for a part on order, leaving her with one functioning washer. She stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure at the time each resident was admitted the facility had a physician order for the resident's immediate care for 1 of 1 resident (Resident #43) reviewed for residents receiving care and services upon admission. The facility failed to ensure Resident #43 had a current physician's order for use of an indwelling catheter as well as its treatment and maintenance after readmission to the facility. The failure could place residents atresidents at risk for not receiving the necessary care and services. Findings included: Review of Resident #43's admission record dated 08/08/24 reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included unspecified fracture of left femur, unspecified fracture of right wrist and hand, vascular dementia, and retention of urine. Review of Resident #43's admission MDS assessment, dated 07/17/24, reflected a BIMS score was 00 indicating severely impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Residents #29), reviewed for care plans. The facility failed to revise and update Resident #29's comprehensive care plan with new diet orders. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the admission Record dated 8/8/24 revealed Resident #29 was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease, diabetes mellitus, acquired absence of right leg below the knee, congestive heart failure, unspecified protein-calorie malnutrition, and morbid obesity. Record review of the quarterly MDS dated [DATE] revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services who met at a minimum one of the following qualifications: a certified dietary manager or certified food service manager, or had a similar national certification for food service management and safety from a national certifying body, or had an associate's or higher degree in food service management or in hospitality, or had 2 or more years of experience in the position of food and nutrition services in a nursing faciltiy and had completed a course of study in food safety management for one of one Dietary Manager reviewed for qualifications. The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record review of the staff roster provided by the facility, undated, reflected the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.